兒童貧血(全英文)課件

1、兒童貧血(全英文)Anemia in childhood (小兒(xio r)貧血) 第一頁，共九十四頁。兒童貧血(全英文)第二頁，共九十四頁。兒童貧血(全英文)Disease of hematopoietic system infantile anemia（1）nutritional iron deficiency anemia(IDA)（2）nutritional megaloblastic anemia Primary/immunity thrombocytopenia Purpura(ITP) Leukemia 第三頁，共九十四頁。兒童貧血(全英文)haematogenesis of

2、childrenhematopoiesis -produced blood extramedullary before birth and postnatal mesoblast hepatic medullary 3-15w 6w-6ms 3ms 第四頁，共九十四頁。兒童貧血(全英文)Embryo stage Mesoblastic haematogenesis：3ws begin，8ws weaken, 12-15ws disappears。 liver：8ws begin，6months gradually weaken ,erythroblast、granular cell and m

3、egakaryocyte.第五頁，共九十四頁。兒童貧血(全英文)Embryo stage3、spleen：12ws begin erythrocyte, granule ,lymphocyte4、Haematogenesis of lymphatic organ 1.thoracic gland:8ws 2.lymphatic nodes:11ws第六頁，共九十四頁。兒童貧血(全英文)Embryo stage5、myelo-haematopoiesis：6mons Haematogenesis function emphasis，make various kinds of blood cell

4、s，unique hematogenic organ after birth.第七頁，共九十四頁。兒童貧血(全英文)第八頁，共九十四頁。兒童貧血(全英文)Haematopoiesis postnatal 1、marrow： 2、extramedullary：when requirement of haemopoiesis increase，liver、spleen、lymphadenectasis，hepatomegaly and splenomegaly, in circulating blood immature erythrocytes and granulocytes . 第九頁，共九

5、十四頁。兒童貧血(全英文)Physiological haemolysis Normal newborns have higher hemoglobin(HB) and hematocrit levels and a shortened survival period of the fetal RBCs contributes to the development of physiologic anemia. 第十頁，共九十四頁。兒童貧血(全英文)Physiological haemolysis erythropoiesis abruptly ceases with onset of resp

6、iration at birth, when the arterial oxygen saturation rises toward 95%. levels of erythropoietin (EPO) are low. EPO has a decreased half-life and an increased volume of distribution in newborns. A shortened survival of the fetal RBC also contributes to the development of physiologic anemia. the siza

7、ble expansion of blood volume that accompanies rapid weight gain during the first 3 mo of life adds to the need for increased RBC production. 第十一頁，共九十四頁。兒童貧血(全英文)blood characteristics ages red blood cells(RBC) and HbPhysiological haemolysis and anemia write blood cells(WBC) and classification 4-6 cr

8、oss Platelets 150-250109/L blood volume 8-10% 第十二頁，共九十四頁。兒童貧血(全英文)Red blood cell (RBC) Term newborns have a red cell mass that is higher than at any other time of life. an appropriate condition for the low oxygen environment of intrauterine life. The RBC count is 5.010127.01012, hemoglobin concentra

9、tion is about 150220g/L at birth. The RBC and hemoglobin concentration in preterm infants are slightly lower than those in term infants.第十三頁，共九十四頁。兒童貧血(全英文)Red blood cell (RBC)The wide range of hemoglobin concentration is accounted for by: Variation in how rapidly the umbilical cord is clamped. An i

10、nfants position after delivery. If cord clamping is delayed and the baby is held lower than placenta, both hemoglobin and blood volume are increased by a placental transfusion.第十四頁，共九十四頁。兒童貧血(全英文)Change of HB after birth第十五頁，共九十四頁。兒童貧血(全英文)Reticulocyte第十六頁，共九十四頁。兒童貧血(全英文)Reticulocyte Reticulocyte is

11、 0.04-0.06 in the first 3 days. Reticulocyte decreases to 0.005-0.015 after 4-7 days. Reticulocyte rises to 0.02-0.08 in 4-6 weeks. Reticulocyte is equal to an adults after 5 months. 第十七頁，共九十四頁。兒童貧血(全英文)White blood cell(WBC) The normal number of WBC is higher in infancy and early childhood than late

12、r in life. WBC count is 15109 20109 at birth. After 612 hours, it rise to 21109 28109 and then begins to decrease to 12109 by 1 week. WBC count maintains about 10109 at infant period and approach adults WBC count level by 8 years.第十八頁，共九十四頁。兒童貧血(全英文)White blood cell(WBC) The change in WBC classifica

13、tion is the proportion between lymphocyte and granulocyte. Lymphocyte is about 30% and granulocyte is about 65% at birth, but the later lymphocyte contrary to neutrophile granulocyte decreases. The proportion between lymphocyte and granulocyte is equal at 46 days after birth.第十九頁，共九十四頁。兒童貧血(全英文)Whit

14、e blood cell(WBC) Lymphocyte is about 60% and granulocyte is about 35% subsequently . They are equal at 46 years. After 7 years white cell classification in infants is similar to that in adult.第二十頁，共九十四頁。兒童貧血(全英文)4-6 DaysGranulocyteLymphocyte4-6 yearsChange of proportion in Lymphocyte and Granulocyt

15、e第二十一頁，共九十四頁。兒童貧血(全英文)Platelet count Normal value for the platelet count are about 150250109/L and vary little with age.第二十二頁，共九十四頁。兒童貧血(全英文)Blood volume Blood volume in infants is more than in adults. The newborns blood volume is 10% of his weight and about 300ml on average. A childs is about 8%10%

16、 of his weight.第二十三頁，共九十四頁。兒童貧血(全英文)AnemiaDefination : Anemia is defined as a reduction of the red blood cell volume or hemoglobin concentration below the range of values occurring in healthy persons. Anemia is an absolute decrease in hematocrit , hemoglobin concentration, or the RBC count. Anemia i

17、s not a diagnosis, but a sign of underlying disease.第二十四頁，共九十四頁。兒童貧血(全英文)The criteria of anemiaAgeHb concentration 28 days 145 g/L14 months 90 g/L46 months 100g/L6 months6 years 110g/L614 years 120g/L第二十五頁，共九十四頁。兒童貧血(全英文) Anemia1. Classification 1） degree : mild moderate severe Very severe 2） Morpho

18、logy of RBC3）Causes: lost blood , hemolytic , deficiency of forming Hb and RBC第二十六頁，共九十四頁。兒童貧血(全英文) degree RBC (van /mm3 ) Hb (g/L) Mild 300-400 90-110 Moderate 200-300 60-90 Severe 100-200 30-60 Very severe 100 30 第二十七頁，共九十四頁。兒童貧血(全英文)Morphologynanemia with microcytosis and hypochromianAnemia with

19、macrocytosisnAnemia with normalcytosis Anemia第二十八頁，共九十四頁。兒童貧血(全英文)More anemia MCV MCH MCHCNormal 80-94 28-32 32-38Micro-hypochromia 80 28 94 32 32-38microcytosis 80 28 32-38 mean corpuscular volume(MCV), means corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration(MCHC) 第二十九頁，共九十四頁。

20、兒童貧血(全英文)Causes1.lost blood :acute chronic2. hemolysis Intrinsic membrane hereditary spherocytosis Glycolysis pyruvate kinase hemoglobin sickle cell,unstable Hb oxidation G6PD extrinsic : immune, infection, DIC第三十頁，共九十四頁。兒童貧血(全英文)Causes 3.deficiency of forming Hb and RBC deficiency of hematopoiesis

21、substance medullary hematopoiesis disorder (Aplastic anemia) The inhibition of haematopoiesis induced by: Inflamation Chronic nephritis Toxicity Cancer cells invasion bone marrow 第三十一頁，共九十四頁。兒童貧血(全英文)Symptoms of anemia Asymptomatic: particularly if the anemia develops over a long time. General manif

22、estation: pallor of the skin and mucous membranes, lethargy, malnutrition, growth retardation. liver, spleen and lymph nodes expansion. Digestion system: anorexia, nausea and constipation.第三十二頁，共九十四頁。兒童貧血(全英文)Symptoms of anemia Cardiovascular and respiratory system: tachycardias, increased artery pr

23、essure, wheeze and increased pulse. severe anemia may cause heart expansion and congestive cardiac failure. Nerver system: vertigo, tinnitus, irritability, and disorders of attention. 第三十三頁，共九十四頁。兒童貧血(全英文)2. DiagnosisHistory positive manifestation laboratory tests Blood smear BM Hb ananysis Growth d

24、evelopment nutrition nails fairs liver spleen and lymph notes 5 points: age, course, symptoms, feeding, past medical history ,family history Morphology of RBC, reticulocyte count, WBC, platelet count, bone marrow cell smear, HB ,special examination第三十四頁，共九十四頁。兒童貧血(全英文)3.Treatment Elimination etiolog

25、y General Medicine Intravenous blood Transplantations : BM , stem cells Other第三十五頁，共九十四頁。兒童貧血(全英文) nutritional anemia with microcytosis and hypochromiaDefinition nutritional iron deficiency anemia (IDA) Hb、 most common 、 6-24ms、 special prevention 第三十六頁，共九十四頁。兒童貧血(全英文)Iron metabolism Iron content an

26、d distribution: 2/3 of the iron is present in HB and 1/3 in tissue and transport form. Content of elemental iron (mg/kg)Adult females40Adult males50newborn75第三十七頁，共九十四頁。兒童貧血(全英文)Iron metabolismIron absorption: The primary regulator of iron homeostasis is intestinal iron absorption. Iron absorption t

27、akes place primarily in the duodenum by the enterocytes at the tip of the intestinal villa. Iron must pass though the apical and the then the basolateral membranes of these cells to reach the circulation.第三十八頁，共九十四頁。兒童貧血(全英文)Iron metabolismIron storage: Most body iron is contained in HB, with smalle

28、r amounts bound to ferritin(鐵蛋白) and hemosiderin（含鐵血(ti xu)黃素） in the reticuloendothelial system, myoglobin in muscle, circulating transferring, and iron-containing enzymes. The major iron stores are in the form of ferritin. As iron continues to accumulate in the cell, a second storage form, hemosid

29、erin appears.第三十九頁，共九十四頁。兒童貧血(全英文)Iron metabolismIron characteristics: The fetus absorbs iron from the mother across the placenta. Term infants have adequate reserves for the first 4 months of life. Preterm infants have limited iron stores and because of their higher rate of growth, they outstrip th

30、eir reserves by 8 weeks of age.第四十頁，共九十四頁。兒童貧血(全英文)Iron metabolismIron characteristics: At birth, because of “physiological haemolysis”, much iron is released to plasma and little iron is absorbed from food, During the second stage (about 2 months old), hematopoiesis is increased and more iron is ab

31、sorbed from food, so iron deficiency is rare in this stage. After 4months, development increase, iron in food is deficient and iron stores exhaust, so most iron deficiency anemia occurs in 6 months to 2 years or 3 years old child.第四十一頁，共九十四頁。兒童貧血(全英文)causes1.inadequate iron stores: preterm infant, t

32、ake iron deficiency3.growth and development increased iron requirement4.iron absorb abnormal5.a amount of iron loss: hookworm infestation, repeated venesection, Meckels diverticulum, recurrent epistaxis(反復(fù)(fnf)鼻出血).第四十二頁，共九十四頁。兒童貧血(全英文)pathogenesis IRON Hb microcytosis and hypochromia RBC 第四

33、十三頁，共九十四頁。兒童貧血(全英文)Three stage of iron deficiencyDeficiency of iron progresses in stages iron depletion(ID): tissue iron stores are deleted, under normal condition, this correlates directly with decrease in the ferritin lever, reticulocyte percentage decreases. Iron deficient erythropoiesis(IDE): lo

34、ss of circulating iron. Low serum iron less than 30ug/dl, low transferring saturation and/or elevated total iron binding capacity. 第四十四頁，共九十四頁。兒童貧血(全英文)Three stage of iron deficiency iron deficiency anemia (IDA): iron deficiency following depletion of both marrow store and circulating iron. IDIDEIDA

35、第四十五頁，共九十四頁。兒童貧血(全英文)clinical manifestation1. general manifestation: mild iron deficiency is Asymptomatic , pallor of the skin and mucous mebranes are most evident and lethargy, malnutrition, growth retardation.2. liver spleen and lymph nodes enlarge3. digestion system: anorexia（食欲差）, nausea（惡心( xn)

36、）, constipation（便秘）. diarrhea 第四十六頁，共九十四頁。兒童貧血(全英文)clinical manifestation 4. cardiovascular and respiratory manifestation: tachycardia, increased artery pressure, wheeze, increased pulse. Severe anemia may cause heart expansion and congestive cardiac failure. 5. nervous system manifestation: vertigo

37、, irritability.第四十七頁，共九十四頁。兒童貧血(全英文)clinical manifestation Main signs may be pallor of the skin and mucous membranes. Severe anemia may cause congestive cardiac failure. IDA in infancy and early childhood is associated with developmental delay and poor growth.第四十八頁，共九十四頁。兒童貧血(全英文)laboratory test1.bl

38、ood smear2.bone marrow3.iron metabolism 第四十九頁，共九十四頁。兒童貧血(全英文)Inequality of size of erythrocytes，small cell，Central olistherozone obviously 第五十頁，共九十四頁。兒童貧血(全英文)hypercellular , erythroid hyperplasia , the development of cytoplasm falls behind nucleus. leukocytes and megakaryocytes are normal.第五十一頁，共九十

39、四頁。兒童貧血(全英文)Bone marrow iron stain：ferrugination grains in the erythocytes.Normal bone marrow iron stain正常正常(zhngchng)骨髓鐵染色骨髓鐵染色I(xiàn)DA iron stain鐵缺乏骨髓鐵缺乏骨髓( su)鐵染色鐵染色第五十二頁，共九十四頁。兒童貧血(全英文)laboratory test The decrease of HB concentration is more than the decrease of red cells count. Blood smear reveals t

40、he more feature of microcyte and hypochromia. MCV80fl, MCH26pg, MCHC0.31. Reticulocyte is normal or slightly decreases. WBC and platelets are normal.第五十三頁，共九十四頁。兒童貧血(全英文)Blood count in iron deficiencyHB75g/L120g/LRBC3.541012/L4.241012/LMCV64fl86flMCHC18.5pg32pgreticulocyte1.3%1.4%WBC7.54109/L7.64109

41、/Lproportionnormalnormalplatelet254109/L257109/L第五十四頁，共九十四頁。兒童貧血(全英文)laboratory test Bone marrow reveals increased basophilic normoblast and polychromatic normoblast. Granulocyte system and megakaryocyte system are normal.第五十五頁，共九十四頁。兒童貧血(全英文)Iron metabolisms Serum ferritin (SF) (血清(xuqng)鐵蛋白) Free

42、erythrocyte protoporphyrin(FEP) Serum iron, total iron binding capacity Iron in bone marrow 第五十六頁，共九十四頁。兒童貧血(全英文)Iron metabolismsIron study ID IDEIDASerum ferritin (SF)Iron store Red blood cell protoporphyrin (FEP) N Percent sideroblasts N Serum iron NN / 第五十七頁，共九十四頁。兒童貧血(全英文)diagnosis first conside

43、r - history + clinical manifestation + blood smear Decide diagnosis-bone marrow + iron metabolism May be see treatment with iron (The bone marrow is hypercellular, with erythroid hyperplasia, the normoblasts may have scanty, and the development of cytoplasm falls behind one of nucleus. leukocytes an

44、d megakaryocytes are normal.)第五十八頁，共九十四頁。兒童貧血(全英文) treatment 1. nursing feeding 2. get rid of etiology 3. iron medicine 4. interfusions blood第五十九頁，共九十四頁。兒童貧血(全英文)Oral administration of simple ferrous salts ferrous sulfate(硫酸亞鐵(li sun y ti) ferrous gluconate（葡萄糖酸亞鐵）ferrous fumaratepolysaccharide iron

45、 Dosage: 4-6mg/kg elemental iron per day Oral iron preparation第六十頁，共九十四頁。兒童貧血(全英文) Administration the iron prior to meals /between to meals.Administration ascorbic acid with iron preparation. Therapeutic course: withdrawal of iron preparation 6-8 weeks after hemoglobin recover to normal level or whe

46、n SF(Serum ferritin) and FEP(Free erythrocyte protoporphyrin) is normal. Oral iron preparation第六十一頁，共九十四頁。兒童貧血(全英文)Parenteral iron preparation To be administered only for gastrointestinal malabsorption or severe intolerance prevents effective oral iron therapy. 第六十二頁，共九十四頁。兒童貧血(全英文)Parenteral iron p

47、reparation A parenteral iron preparation (iron dextran) is an effective form of iron and is usually safe when given in a properly calculated dose, but the response to parenteral iron is no more rapid or complete than that obtained with proper oral administration of iron, unless malabsorption is a fa

48、ctor.第六十三頁，共九十四頁。兒童貧血(全英文)Blood Transfusion With a severe anemia, immediate red blood cell transfusion may advisable, especially in cardiac failure or severe infection, but volume and speed of transfusion must be controlled well. We may transfuse, severely anemia children should be given only 2-3ml/

49、kg of packed cells at any one time. If there is evidence of frank congestive failure, a modified exchange transfusion using fresh-packed RBCs should be considered. 第六十四頁，共九十四頁。兒童貧血(全英文)Iron therapyNotice : 3 points1.Injection iron in danger 2.Reaction : 12-24h(irritability ,appetite )- 36-48h(erythr

50、oid hyperplasia )-48-72h(reticulocytosis)-5-7ds(peaking ) 2-3ws to reticulocytes3.Times: 6-8ws第六十五頁，共九十四頁。兒童貧血(全英文)Prevention4 points mother milk feeding specter food with iron preterm infant第六十六頁，共九十四頁。兒童貧血(全英文) Nutritional megaloblastic anemia Folic acid and vitamin B12 deficiency are primary caus

51、es of megaloblastic anemia. 第六十七頁，共九十四頁。兒童貧血(全英文) The clinical features include anemia， the decrease of red cell is more than that of HB， the volume of red cell is larger than normal.第六十八頁，共九十四頁。兒童貧血(全英文)Causes 1.less intake 2.absorb abnormal 3.drug interactions 4.requirement increased 第六十九頁，共九十四頁。兒

52、童貧血(全英文)Pathogenesis folic acid folic acid with 4 hydrate vitamin B12 DNA Hb very large RBC Megaloblastic with Lot of Hb dihydrofolate reductase (THFA)第七十頁，共九十四頁。兒童貧血(全英文)VitaminB12 is importance in synthesis of nerve. deficiency of vitaminB12 can lead to discord of neurology psychology. In the macr

53、ocytic anemia produced by deficiency of vitamin B12, the symptoms and signs include those of anemia and neuropathy. nVitamin B12 deficiency neurology psychology symptom第七十一頁，共九十四頁。兒童貧血(全英文) Patients develop a demyelinating lesion of neurons of the spinal column and cerebral cortex. This condition re

54、sults in paresthesias of the hands and feet, unsteadiness of gait, and eventually memory loss and personality changes. There is retard of intellective and physical development. Trembling of Extremities or head, hypertension of muscle, tendon reflex reinforcement, positive Babinskis sign may appear.第

55、七十二頁，共九十四頁。兒童貧血(全英文)Clinical manifestation1. General features: puffiness, poor nutrition, hair yellowed, mild edema, petechia (plt), mucocutaneous hemorrhage.2. feature of anemia: lethargy, extramedullary3. neurology psychology: irritability, vertigo.4. digestive symptoms : anorexia, nausea, diarrhe

56、a. 第七十三頁，共九十四頁。兒童貧血(全英文)Laboratory tests 1.blood smear 2.bone marrow3.blood biochemistry tests4. others第七十四頁，共九十四頁。兒童貧血(全英文)variation in BRC shape and size, macrocytosis , reticulocyte count is low , nucleated RBCs and megaloblastic morphology are often seen , thrombocytopenia 第七十五頁，共九十四頁。兒童貧血(全英文)H

57、ypercellular , Megaloblastic changes, hypersegmentation 第七十六頁，共九十四頁。兒童貧血(全英文)Laboratory tests Blood routine examination: macrocytic anemia, the decrease of red cell count is more than the decrease of HB. MCV94fl, MCH32pg. Rreticulocyte is decrease. WBC and platelets are also decreased. Bone marrow:

58、increased basophilic normoblast and polychromatic normoblastic. Granulocytic system and megakaryocyte system : normal/less than normal.第七十七頁，共九十四頁。兒童貧血(全英文)Laboratory tests Vitamine B12: normal serum vitamin B12 levels range from 200-800ng/L, B1212ng/L reveals B12 deficiency. Folate : normal serum f

59、olate levels range from 5-6ug/L, folate 3ug/L reveals deficiency. others :LDH : serum lactic dehydrogenase(LDH) is increase第七十八頁，共九十四頁。兒童貧血(全英文)Diagnosis first consider - history + clinical manifestationMarked symptoms and signs of central nervous system.( it supports defiency of vitamin B12.) + .bl

60、ood smear decide diagnosis-.bone marrow + metabolism(To distinguish the deficiency of folic acid with the deficiency of vitamin B12.) maybe see treatment with medicine 第七十九頁，共九十四頁。兒童貧血(全英文)Treatment1.nursing feeding 2.get rid of etiology 3. medicine vit B12 ,folic acid 第八十頁，共九十四頁。兒童貧血(全英文)Vitamin B1